Experts say health reform means problems for primary care

More new patients is likely to lead to a doctor shortage.

Third-year intern Dalia Elramady tends to patient Latasha Daniel, 33, during her visit Wednesday to the Family Medicine Residency Program operated by St. Vincent's HealthCare. Medical providers are questioning whether there will be enough primary-care doctors like Elramady to handle the newly insured.

The new federal health reform law expands coverage to 32 million Americans, including tens of thousands on the First Coast. Now, who will treat them?

Those in primary care - practicing it and teaching the next generation of front-line physicians - say they're not exactly sure. Although the wide-ranging law offers several measures aimed at retaining and creating primary doctors, there still might not be enough doctors to go around, particularly in poor and rural areas, they say.

"You're going to have all these people with some coverage to get their care, and yet where are they going to go?" asked Joe Crozier, executive director of the Northeast Florida Area Health Education Center. The agency runs a program that enables medical students and resident physicians to train in rural and underserved parts of the state.

The health reform law could force patients, mostly the new ones, to wait longer to see a primary-care doctor.

Before President Barack Obama signed the bill last month, the American Academy of Family Physicians was already predicting a shortage of nearly 40,000 family doctors nationwide by 2020. That almost certainly will grow because of the law, experts say.

In Florida, the existing need for primary care is even more dire than the nation as a whole, according to a federal analysis. About 15 percent of Florida residents live in areas where there is a shortage of primary-care professionals; nationally, about 12 percent live under such circumstances.

Areas federally designated as short on doctors in Northeast Florida include all of Baker and Nassau counties and low-income parts of western St. Johns County and the Northside of Jacksonville.

Although northern Clay County isn't on the list, it seems like it should be, said William Choisser, a family physician in Orange Park. Over the past year, four family doctors in Clay have stopped practicing in the area, leaving scores of patients looking for a new gatekeeper to their care, he said.

Choisser already works 50-hour weeks and would like to hire a second physician assistant to handle his office's growing workload. But he can't afford to pay one, he said.

Therein lies one of primary care's biggest pitfalls.

The average income for a family doctor is about $180,000 a year, less than half the pay of a dermatologist or a urologist, according to a 2009 survey by the Medical Group Management Association. For the many medical students who leave college with more than $100,000 in student loans, primary care is often not their first job choice.

The result: Since 1961, the proportion of doctors who are primary-care physicians has dipped from about 50 percent to 38 percent, according to the American Academy of Family Physicians.

"It's stressful to be in primary care," Choisser said. "It takes a lot of knowledge to operate a business with such a low margin to keep alive."

The new reform law tries to reverse that trend. Among other things, it includes payment boosts from primary-care physicians who treat Medicare and Medicaid patients and increases funding for a program that repays student loans for qualifying physicians. Such measures might not be enough to offset the greater demand the law creates, said Tad Fisher of the Florida Academy of Family Physicians.

Florida's biggest problem is that its hospital aren't training enough new doctors, he said. The state is No. 4 in population but No. 44 in the number of resident positions. Where a doctor's residency is located matters because studies show that three out of five doctors tend to stay put afterward.

The reform law steers scores of unused slots Florida's way. That will help, Fisher said, but it may just be a drop in the bucket.

"End of life care was obliquely addressed in the bill, and everyone called it "death panels." It's not about death panels, but exactly as you say, a way to curb unnecessary costs for testing and care of DNR patients (do not resuscitate) and patients who have explicit requests for long-term care, testing, and experimental procedures.
The plan is to include counseling to elder patients, to document their wishes as to care. If the documentation exists, then the argument can be made to refuse payment for further unwanted, unnecessary procedures and testing.
If you have ever been responsible for a loved one's life when their recovery and/or quality of life is doubtful, you know how difficult it is when there is inadequate documentation or unknown wishes. Where do you draw the line? What is heroic measures? Does that include an IV to keep the patient hydrated, or a ventilator to help him breath? It's a very difficult situation to be in, for the family and for the medical provider.

I think tort reform is already accomplished by the health care bill. If everyone has insurance and access to care, there are no medical costs to recover. That only leaves gross negligence. The other side of it is the lawyer who refers clients (patients) to specific lawyer-friendly doctors. The doctor can no longer withhold the doctor's bill until the suit is settled because the patient's insurance must be filed at time of service. Communication of medical records is also covered under the new law, so any inadequate testing done for "proof" of an injury will be subject to scrutiny."

PJ I agree the bill begins to address end of life costs by beginning discussions. But in the end it will do very little to actually curb costs because it is still left up to the individual. However, when I suggest reducing end of life care it is not a mere discussion about patient wishes. It is actually limiting care. It cannot be left up to the individual to decide because at a time of stress what was once a firm decision can flip flop and families may not necessarily follow the wishes of Grandma but maybe their own due to the emotions that are present. If we want to cut costs, what needs to happen is what happens in European countries, which is flat reduction in options offered/available unless the individual is willing to cover the costs. Thus if you want to consume more for little return then you have to pay for it and personal responsibility comes into play. It also helps to deter people from selecting futile care because now they actually feel some of the burden.

As far as tort reform. I am sorry but this bill does nothing in that regards. Yes you my reduce money awarded for health costs. But as I stated before the cost for that is a drop in the bucket compared to defensive medicine costs. People will still continue to sue for bad outcomes (i.e. known complications of treatment that have been explained) which is not the same as negligence and malpractice. Attorney's will still collect money on these baseless suits because insurance companies find it cheaper to settle than to fight some smaller cases. So defensive medicine will still be there. As far as not ordering duplicate tests, electronic records will help. But we are not talking about duplicate tests but actually extra tests that are ordered to document what is believed based on the scenario and to rule out the 1 in a million disease. Thus those costs are still there.

Also electronic records are not really going to be transportable. There are a myriad of electronic record systems and there is no national database due to information security. So in reality information will still be segregated.

There needs to be legislation to require all electronic medical record systems to have a standard base format so that our information can be placed on a jump drive like device and handed to us after it is updated with every lab result and doctors visit note after each visit so that if we go somewhere else that information is available to the next doctor. All people would also obviously be required to have one of these drives that could be secured by a variety of methods. Then you could reduce duplicate tests, but not superfluous tests ordered for defensive medicine.

These guys had a chance to really do something right for everyone, but unfortunately they made a massive pork filled bill which will ultimately raise costs (direct and indirect) for healthcare for a variety of reasons. If they had started small and then expanded at least we could correct as we go along. But as we all know once a government entitlement program is started it will never end until it is bankrupt. So if you are dealing with 1/6th of your GDP it is moronic to make wide sweeping changes that are difficult to reverse because a bad move is disastrous. The fact that the president was proudly comparing the significance of this bill to the creation of Social Security and Medicare is laughable since both of those programs are soon to be bankrupt.

For the sake of our country and our healthcare I hope I am wrong, but there are very few scenarios where this bill will lead to improved access, lower costs, and better outcomes.

gator1977 said "The only way to truly reign in cost is to stop providing exhorbitant endoflife care. Nearly 20% of healthcare costs are due care at the end of life. " ...tort reform. All of the calculations on cost of malpractice to the system that the so called experts put forth are based mainly only on jury awards and premiums, but very few actually discuss the hidden cost which are tests that are ordered simply to document what the physician already knows in order to protect against lawsuits. ..." "...tests are probably ordered either for documentation or to avoid missing a 1 in a million diagnosis that you can be held liable for."

End of life care was obliquely addressed in the bill, and everyone called it "death panels." It's not about death panels, but exactly as you say, a way to curb unnecessary costs for testing and care of DNR patients (do not resuscitate) and patients who have explicit requests for long-term care, testing, and experimental procedures.
The plan is to include counseling to elder patients, to document their wishes as to care. If the documentation exists, then the argument can be made to refuse payment for further unwanted, unnecessary procedures and testing.
If you have ever been responsible for a loved one's life when their recovery and/or quality of life is doubtful, you know how difficult it is when there is inadequate documentation or unknown wishes. Where do you draw the line? What is heroic measures? Does that include an IV to keep the patient hydrated, or a ventilator to help him breath? It's a very difficult situation to be in, for the family and for the medical provider.

I think tort reform is already accomplished by the health care bill. If everyone has insurance and access to care, there are no medical costs to recover. That only leaves gross negligence. The other side of it is the lawyer who refers clients (patients) to specific lawyer-friendly doctors. The doctor can no longer withhold the doctor's bill until the suit is settled because the patient's insurance must be filed at time of service. Communication of medical records is also covered under the new law, so any inadequate testing done for "proof" of an injury will be subject to scrutiny.

I agree with you, Medicare reimbursement is ridiculously low, and Medicaid is just charity from the physician at the rate of reimbursement.. The biggest cuts are going to be subsidies to insurance companies that provide Medicare Advantage. The government subsidy averages $10,000 per insured.
The economic model is based on the increase in the number of insured people who will pay premiums. Those people are not going to be on Medicare (granted, number of Medicare people does increase as population ages). Medicare is not free to the patient either, because they pay premiums and have copays.
The insurance companies have cherry-picked their patients, preferring (rightly so) to insure younger, healthier people who have jobs and automatic payroll deductions. They are low-risk and have high premiums, resulting in huge profits.
The insurance to older people is higher-risk, but still has the automatic guaranteed payments through Medicare deductions, as well as government subsidies.
It seems to me that insurance plans today are similar to the exotic mortgages we saw this past decade. Instead of all these separate plans for high risk, low risk, employed, unemployed, autopay, geography, etc. , the model that looks at the industry as a whole throws all patients into the same pool.
Health reform requires everyone to have insurance. That is a huge influx of new patients to the insurance companies, all paying premiums. That will increase profits to the insurance industry, which does not justify a decrease in medical provider reimbursements. The loss of government subsidies to insurance companies will also be offset by the number of people insured.
Perhaps that $10,000 per patient Medicare subsidy that the government will no longer pay to insurance companies will go toward offsetting the cost of Medicaid.

What is lost in all of this is that all doctors are about to take a 21% cut in pay. Not only medicare. Insurance reimbursement rates are linked to medicare rates. So if you cut one, you in effect cut the other. Now most offices have 60-70% of their revenue go towards covering overhead (office space, equipment, furniture, nurses, billers, etc, etc). So if you are currently surviving on 30%, if you remove 21% you are going to have an office that can no longer make it as noone is going to work for 1/3 of their current salary and assume all the liablity that comes along with practicing medicine. So you will have offices close, especially in rural areas where most patients are medicare or medicaid. So yes all patients will have less access, not just to primary care but all physicians.

As far as Primary Care doctors, they do make less than most specialist. But you have to remember their residency training is also shorter sometimes 1/2 that of many specialist. So if you take the additional money (approx 130,000-150,000) they are making for those 3-4 years above what a resident is paid and invest this money, they in the end are not to far off what a specialist makes if money was invested properly. You also have 3 -5 fewer years of interest accumulating on med school loans. So stealing from Peter to pay Paul, doesn't seem fair does it. You will then have a shortage of specialist. Maybe the cuts should occur to Hospital, Pharma, and equipment manufacturer profits since they are not the ones actually providing care.

The Mayo Clinic has already started turning away new medicare patients from primary care facilities in Arizona because they lose money on each patient due to poor reimbursement from medicare that is not in line with inflation and cost to provide care. This is despite all of their efficiencies and cost saving measures.

Single payor is also not the answer. You add government bueracracy and you have less money going to actual patient care.

We need change but the current plan is not it and unfortunately I see the collapse of the current quality we have with increased costs.

The only way to truly reign in cost is to stop providing exhorbitant endoflife care. Nearly 20% of healthcare costs are due care at the end of life. All countries with natioanlized healthcare ration this care: example being no dialysis for those over 65 in some European countires unless paid for by patient. But obviously this is politically untenable in this country because no politician will truly standup to fight the things that truly raise our costs. Unfortunately we can't have our cake and eat it too without bankrupting the system and our country. You want to cut another 20-30% in costs, then you need tort reform. All of the calculations on cost of malpractice to the system that the so called experts put forth are based mainly only on jury awards and premiums, but very few actually discuss the hidden cost which are tests that are ordered simply to document what the physician already knows in order to protect against lawsuits. A study would have to performed at many sites where physicians are asked the purpose behind the ordering of all tests for one month and then calculate based on this. Approximately 20-30% of tests are probably ordered either for documentation or to avoid missing a 1 in a million diagnosis that you can be held liable for. Malparactice is no longer about negligence, but people are suing for bad outcomes which are known to occur and are winning. Noone is suggesting no payouts for true negligence, but there needs to be some sort of screening of lawsuits by physician and ethicist tribunals to judge merit of true negligence and not just bad outcome. Trial attorney's that practice on a contigency basis should have to pay the attorney's fees for the physician if they lose. This would also cut down on frivolous lawsuits that are filed only in hopes for settlement which is cheaper for the insurance companies than to pay for attorney's fees to actually fight the case. An example of a country we could follow in this regards is New Zealand. All physicians, lawyers, and taxpayers fund a national fund. If someone feels malpractice occurs, they file suit against the fund. The suit is then reviewed by a board made of physicians, ethicist, lawyers, and general populace. If negligence is found and their is true malpractice then the person is awarded funds from the fund commisurate with reasonable pain and suffering and medical costs. This prevents ridiculous amounts like the $60 million award for damage to a woman's labia as was awarded in the Bronx. Some would argue that most peoples lives including the physician's life is not worth 60 million so why is one labia?

There are plenty of ways to cut costs. But god forbid our politicians actually do the right thing and do them regardless of their personal carrers. Well I guess they can't put themselves out of business either since most are trial lawyers.

No one really knows how medicine will change, but we all know it will change. In the 1970's and 1980's there were too many doctors. Even today, there is great competition between doctors and medical facilities for patients. One of the issues addressed by health care reform is the need for better communication and continuum of care between medical providers.

"Medical centers at the high end, like UCLA and New York University Hospital, employed on average two to three times as many doctors per patient as did hospitals at the low end. But these high-end hospitals did not produce better outcomes than hospitals using relatively few doctors, like the Mayo Clinic, Duke, and Stanford. Other studies show that these latter hospitals consistently deliver higher-quality care—and not just to dying patients—using fewer physicians. And the cost of care is much lower."

"Why would more doctors lead to worse care, and fewer doctors to better care? More tests and procedures always entail more risk, and for care that’s unnecessary, the ratio of benefit to risk is zero. What’s more, where numerous doctors, particularly specialists, are routinely involved in a patient’s case, the potential for miscommunication and confusion multiplies. Modern medicine should be a team sport, but it is often practiced as if everybody is running a different play."http://www.theatlantic.com/magazine/archive/2007/12/overdose/6452/2/?

"Most hospitals are organized by traditional specialties, each with its own medical perspective, records, and business practices. You may have been seeing the same gynecologist for 20 years, but if you get referred for a hysterectomy, the surgeon's office treats you as if you dropped into the waiting room from another planet,"
"2006 Cleveland Clinic abandoned the traditional departments in favor of 25 "institutes" organized by disease or organ system. This works well for patients, who don't care whether their back pain is cured by a rheumatologist, a neurologist, or an orthopedic surgeon. But, says Regina Herzlinger, an expert in health-care economics at Harvard Business School, it runs afoul of the dominant fee-for-service system of medical billing, which discourages cooperation across fields. When Duke University Medical Center set up a disease-management system for congestive heart failure, coordinating the efforts of cardiologists, primary-care doctors, pharmacists, and nurse practitioners, it drove down the cost of treatment by 40 percent in a single year, while reducing readmissions and improving outcomes. But that highlighted the central paradox of health-care economics: a patient's "cost" is the hospital's "revenue." The unintended result of the Duke experiment, says Herzlinger, was that the unit lost tens of millions of dollars a year. The chief beneficiaries were the insurance companies, which saved on reimbursements."http://www.newsweek.com/id/224585/page/1